Download b. Have you ever had radiation b. If not currently on HRT, were you

BREAST MAGNETIC RESONANCE IMAGING (MRI)
Date
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Chart #
Patient name
Date of Birth
/
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Age
Height
Weight
Breast Magnetic Resonance Imaging (MRI) is one of the most advanced diagnostic imaging tools available in medicine today.
Using magnetic fields and radio frequency coils, detailed cross-sectional images of your breasts are obtained to further evaluate
them. MRI does NOT use radiation and is completely painless. There are no known side effects Your examination will be
performed by a highly skilled Registered Technologist under the supervision of the Clinical Breast Radiologist.
1. Have you had a prior MRI diagnostic imaging study?
If yes, please list:
Body part
2. Have you ever been diagnosed with breast cancer?
a. Have you ever had chemotherapy?
Yes No
Date
b. Have you ever had radiation
Yes
Yes
Yes
No
No
No
If yes, which type?
Partial
Whole
c. Have you ever taken anti-hormonal therapy?
Yes
No
Facility
If yes, year? __________
If yes, how long? _________________________________
3. Have you experienced any problem or reaction to a previous MRI exam (e.g., shortness of breath, rash, etc.)?
If yes, please describe reaction:
Yes
No
4. Have you had an injury to the eye involving metallic substances (e.g., metal slivers, shavings, foreign body, etc.)?
If yes, please describe:
Yes
No
5. Have you ever been injured by a metallic object or foreign body (e.g., BB, bullet, shrapnel, etc.)?
If yes, please describe:
Yes
No
6. Are you currently taking or have you recently taken any medication?
If yes, please list:
Yes
No
7. Are you allergic to any medication?
If yes, please list:
Yes
No
8. Date of last menstrual period:
/
/
Postmenopausal?
Yes No
a. If post menopausal, are you currently on hormone replacement therapy (HRT)?
Yes No
If yes, please list name of hormone:
how long?
b. If not currently on HRT, were you ever on HRT in the past?
Yes, how long?
9. Please answer yes or no below:
a. Are you pregnant or experiencing a late menstrual period?
Yes No
b. Are you currently breastfeeding?
Yes No
c. Has your uterus been removed?
Yes No
d. Have your ovaries been removed?
Yes No
e. Have you had uterine ablation?
Yes No
f. Are you currently taking birth control?
Never
Yes, how long?
g. Do you currently have an IUD in place?
Yes
No
10. Are you currently taking any type of fertility medication or having fertility treatments?
If yes, please list:
11. Have you ever taken fertility medication in the past?
If yes, please list:
Yes
No
No
Previously, how long?
Yes
No
Please indicate if you have any of the following:
Yes
Yes
Yes
Yes
No
No
No
No
Kidney disease
Kidney transplant
Liver (hepatic) disease
Diabetes
Yes
Yes
Yes
Yes
No
No
No
No
Kidney failure
Anemia or any blood disease
Seizures
Hypertension (high blood pressure)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Vascular access port and/or catheter
Radiation seeds or implants
Any metallic fragment or foreign body
Wire mesh implant
Tissue expander (e.g., breast)
Surgical staples, clips, or metallic sutures
Joint replacement (hip, knee, etc.)
Bone/joint pin, screw, nail, wire, plate, etc.
Shunt (spinal or intraventricular)
IUD, diaphragm, or pessary
Dentures or partial plates
Tattoo or permanent makeup
Body piercing
Breathing problem or motion disorder
Hearing aid
(Remove before entering MR system room)
Claustrophobia
If yes to any above, please list medications:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Aneurysm clip(s)
Cardiac pacemaker or lead
Electronic implant or device
Magnetically-activated implant or device
Neurostimulation system
Spinal cord stimulator
Internal electrodes or wires
Bone growth/bone fusion stimulator
Cochlear, otologic, or other ear implant
Insulin or other infusion pump
Implanted drug infusion device
Eye prosthesis or lens implants
Heart valve prosthesis
Eyelid spring or wire
Artificial or prosthetic limb
Stent, filter, or coil
Breast Implants
If yes, are they:
Saline or Silicone
Before entering the MRI environment, you MUST REMOVE all metallic objects including hearing aids, dentures, partial plates,
keys, beeper, cell phone, eyeglasses, hair pins, barrettes, jewelry, body piercing, safety pins, paperclips, money clip, credit cards,
bank cards, magnetic strip cards, coins, pens, pocket knife, nail clipper, tools, clothing with metal fasteners, & clothing with metallic
threads.
Please consult the MRI Technologist or Radiologist if you have any question or concern BEFORE you enter the MRI environment.
NOTE: You will be required to wear earplugs during the MRI procedure.
I understand that I will receive an injection (usually in the arm) of a contrast enhancement agent called gadolinium that
helps to highlight various structures in the breast tissue. The gadolinium is administered through a small intravenous
catheter which is placed by a certified technologist or registered heath care professional.
I attest that the above information is correct to the best of my knowledge. I have read and understand the contents of this form and
had the opportunity to ask questions regarding the information on this form and the MRI procedure that I am about to undergo.
Signature of Person Completing Form:
Form Completed By:
Patient
Relative
Date
/
/
Nurse
Print name
Relationship to patient
Form Information Reviewed By:
Print name
MRI Technologist
Radiologist
Signature
Other
2015v10